Delivery Follow Up

Thank you, for taking a moment to complete this follow up form so that we can properly update and close out your file. If you have delivered a baby since the last time you came to the Southern Tier Pregnancy Resource Center, please call us at 737-6952 to make an appointment to stop in and pick up a New Mom's Gift that we have available for you. If you have lost a child due to miscarriage or abortion, we also invite you to call us if you would like someone to talk to.

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Did you receive a pregnancy test at the STPRC? *

YesNo

Did you receive an ultrasound at the STPRC? *

YesNo

I delivered my baby on (date): *

My child's name is: *

Choose One *

MaleFemale

My child's birth weight was: *

My child's birth length was: *

-OR-Since speaking with someone at the STPRC regarding my pregnancy, I decided not to parent my child. Instead, I have chosen:

Adoption. I gave birth on (date): *

Abortion. My procedure was on (date): *

Do you feel you were treated with kindess and respect by the staff when you came to the STPRC? *

YesNo

If you are able to recall, what was the name of any and all staff or volunteers that have assisted you at the STPRC? *

Did our staff seem interested and concerned about you and your situation? *

YesNo

Do you feel you were given adequate information to make an informed decision in regards to your pregnancy? *

YesNo

Would you recommend or refer others to the Southern Tier Pregnancy Resource Center? *

YesNo

Any additional comments: *

Thank you for taking a moment to complete this questionnaire. Please remember, that regardless of your decision, we care about you!We are here to offer any further assistance or support that you may need, so do not hesitate to call us.